Menopause Clinic Secretary the Northern Contraception, Sexual Health and HIV Service the Hathersage Centre 280 Upper Brook Street Manchester M13 0FH

The Menopause Clinic Secretary The Northern Contraception, Sexual Health and HIV Service The Hathersage Centre 280 Upper Brook Street Manchester M13 0FH

Tel: 0161 701 1555

Menopause Clinic

Please complete and return to the address above Once reviewed we will contact you for an appointment in the menopause clinic

Date you first made contact with us ______Name: Miss/Mrs/Ms ______Address: ______Date of Birth ______Telephone number: ______Name of GP: ______When was your last menstrual period? ______Have you had a hysterectomy? Yes/No If yes, when? ______Why did you have to have the hysterectomy? ______When was your last smear? ______Have you had any other gynaecological problems? (Please give details) ______How many children have you had? _____ Any miscarriages or terminations? ______List any serious illnesses you have had with dates: ______List any operations you have had with dates: ______Do you get hot flushes? Yes/No If yes, when did they start? ______If No, have you had any HRT during the last 3 months? Yes/No ______Please list any medicines or pills you are taking (or bring the bottles with you when you come in) ______What treatment have you had for your present problem? ______www.mft.nhs.uk

Incorporating: Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • Royal Manchester Children’s Hospital • Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester • Wythenshawe Hospital • Withington Community Hospital • Community Services

Symptom Assessment

To help us with your assessment please indicate the extent to which you are affected by the following symptoms.

Please tick as appropriate

Not at all A little Quite a lot Extremely Not applicable Hot Flushes Night time sweats Headaches Palpitations Difficulty sleeping Tiredness Lack of Energy Irritability Reduced Concentration Short term memory problems Feeling anxious Feeling unhappy Mood swings Joint pains Loss of interest in sex Vaginal dryness Change in vaginal sensation Pain during sex Itching of vulva or vagina Burning of vulva or vagina Passing urine often Passing urine at night Burning discomfort on passing urine Urinary infections Leaking of urine